Patient Safety in Surgery最新文献

Background: Traction tables have long been utilized in the management of fractures by orthopaedic surgeons. The purpose of this study was to systematically review the literature to determine the complications inherent to the use of a perineal post when treating femur fractures using a traction table.

Methods: A systematic review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) using PubMed, EMBASE, and Cochrane Library. The search phrase used was "fracture" AND "perineal" AND "post" AND ("femur" OR "femoral" OR "intertrochanteric" OR "subtrochanteric"). Inclusion criteria for this review were: level of evidence (LOE) of I - IV, studies reporting on patients surgically treated for femur fractures, studies reporting on patients treated on a fracture table with a perineal post, and studies that reported the presence or absence of perineal post-related complications. The rate and duration of pudendal nerve palsy were analyzed.

Results: Ten studies (2 prospective and 8 retrospective studies; 2 LOE III and 8 LOE IV) were included consisting of 351 patients of which 293 (83.5%) were femoral shaft fractures and 58 (16.5%) were hip fractures. Complications associated with pudendal nerve palsies were reported in 8 studies and the mean duration of symptoms ranged between 10 and 639 days. Three studies reported a total of 11 patients (3.0%) with perineal soft tissue injury including 8 patients with scrotal necrosis and 3 patients with vulvar necrosis. All patients that developed perineal skin necrosis healed through secondary intention. No permanent complications relating to pudendal neurapraxia or soft tissue injuries were reported at final follow-up timepoints.

Conclusion: The use of a perineal post when treating femur fractures on a fracture table poses risks for pudendal neurapraxia and perineal soft tissue injury. Post padding is mandatory and supplemental padding may also be required. Appropriate perineal skin examination prior to use is also important. Occurring at a higher rate than previously thought, appropriate post-operative examination for any genitoperineal soft tissue complications and sensory disturbances should not be ignored.

Background: Open laparotomy with gastroenterological surgery is a surgical procedure results in a relatively high rate (about 10% or more) of incisional surgical site infection (SSI). To reduce incisional SSI after open laparotomy, mechanical preventors, such as subcutaneous wound drainage or negative-pressure wound therapy (NPWT), have been tried; however, conclusive results have not been obtained. This study evaluated the prevention of incisional SSI by first subfascial closed suction drainage after open laparotomy.

Methods: A total of 453 consecutive patients who underwent open laparotomy with gastroenterological surgery by one surgeon in one hospital (between August 1, 2011, and August 31, 2022) was investigated. Same absorbable threads and ring drapes were used in this period. Subfascial drainage was used in consecutive 250 patients in the later period (between January 1, 2016, and August 31, 2022). The incidences of SSIs in the subfascial drainage group were compared to those of in the no subfascial drainage group.

Results: (a) No incisional SSI (superficial and deep) occurred in the subfascial drainage group (superficial = 0% [0/250] and deep = 0% [0/250]). As a result, incidences of incisional SSI of the subfascial drainage group were significantly lower than those of the no subfascial drainage group (superficial = 8.9% [18/203]; deep = 3.4% [7/203]) (p < 0.001 and p = 0.003, respectively). (b) Four out of seven deep incisional SSI patients in the no subfascial drainage group underwent debridement and re-suture under lumbar or general anesthesia. (c) There was no significant difference in the incidences of organ/space SSI of the two groups (3.4% [7/203] in the no subfascial drainage group and 5.2% [13/250] in the subfascial drainage group) (P = 0.491).

Conclusion: Subfascial drainage was associated with no incisional SSI after open laparotomy with gastroenterological surgery.

Background: Invasive surgical procedures carry risk of harm to patients. In addition to avoidable harm, disparities between patient expectations and the outcome of a procedure may lead to patient injury claims. The follow-up of claims and compensation is an important entity for patient safety. The number of claims should be related to the surgical volume, so that a healthcare provider can benchmark with similar organizations and see if its trends are developing favourably or deteriorating. Our objective was to find out the claims and compensation rates due to surgery in an insurance-based system.

Methods: Data related to surgical claims and reference volume in the period 2011-2015 were collected from the claim register of the Finnish Patient Insurance Centre and benchmarking community register of Finnish operating departments. The data included age, gender, hospital, year of surgery, surgical code, and outcome of the claim.

Results: There were 8,901 claims related to the corresponding reference group of 1,470,435 surgical procedures. The claims rate was 0.61% and compensation rate was 0.22%. Trends for claims and compensation rates decreased over the study period. In high volume procedures, a low compensation rate was detected for excision of tonsils and adenoids, Caesarean section and extracapsular cataract operations using the phacoemulsification technique. A high compensation rate was detected for primary prosthetic replacement of the hip and knee joints and decompression of spinal cord and nerve roots. Unreasonable injury (death or permanent deterioration of health) was compensated in 2.4 per 100,000 procedures.

Conclusions: Register data research in a no-fault patient insurance system revealed a claims rate of 6 per 1,000 procedures and compensation rate of 2 per 1,000 procedures. A decreasing trend in both rates over the study period was detected. Different surgical procedures exhibit varying claims and compensation rates.

The distal great saphenous vein is a popular site for venous access by means of percutaneous cannulation or venous cutdown in a hemodynamically unstable patient. The aim of this study was to precisely define the surface anatomy and dimensions of the distal part of the great saphenous vein to facilitate the aforementioned procedures. Cross-sectional anatomy of the distal saphenous vein was studied in 24 cadaveric ankles sectioned at a horizontal plane across the most prominent points of the medial and lateral malleoli. The curvilinear distance from the most prominent point of the medial malleolus to the center of the saphenous vein, its widest collapsed diameter and skin depth were obtained. The great saphenous vein was located at a mean distance of 24.4 ± 7.9 mm anterior to the medial malleolus. The mean widest collapsed diameter was 3.8 ± 1.5 mm. The mean distance from the skin surface to the vein was 4.1 ± 1.2 mm. These measurements could be used to locate the saphenous vein accurately, particularly in hemodynamically unstable patients with visually indiscernible veins.

Background: Ipsilateral femoral neck and hip fractures are uncommon high energy injuries. In the literature no single method of treatment has emerged as superior to the others. A recent publication has documented the successful application of the rendezvous technique using dual-implants for treating these injuries. However in some cases, this technique may fail and revision surgery is required.

Case presentation: A 67-year old man sustained ipsilateral fractures of his femur and femoral neck in a road traffic accident. His injuries were treated by a dual construct consisting of a retrograde femoral nail and dynamic hip screw. Three months after surgery the hip screw cut out of the femoral head necessitating revision to a total hip arthroplasty. Surgery was carried out using a single stage two part procedure on a standard operating table without having to reposition or redrape the patient. There were no postoperative complications and at 1 year from surgery the patient is satisfied with the result and has returned to work.

Conclusion: Conversion hip arthroplasty in the presence of dual implants is a technically challenging and unpredictable procedure, with an increased risk of complications. Our surgical approach provides a framework for orthopedic surgeons to safely perform this complex procedure.

Objectives: Intracranial pressure (ICP) monitoring is recommended for severe traumatic brain injuries (TBI) but some data suggests it may not improve outcomes. The objective was to investigate the effect of ICP monitoring among TBI.

Methods: This retrospective observational cohort study (1/1/2015-6/1/2020) included severe TBI patients. Outcomes [discharge destination, length of stay (LOS)] were compared by ICP monitoring and were stratified by GCS (3 vs. 4-8), α < 0.05.

Results: Of the123 patients who met inclusion criteria, 47% received ICP monitoring. There were baseline differences in the two groups characteristics, ICP monitored patients were younger (p = 0.02), had a subarachnoid hemorrhage less often (p = 0.04), and a subdural hematoma more often (p = 0.04) than those without ICP monitors. ICP monitored patients had a significantly longer median LOS (12 vs. 3, p < 0.01) than patients without monitoring. There was a trend towards more ICP monitored patients discharged home (40% vs. 23%, p = 0.06). Among patients with GCS = 3, ICP monitored patients had a longer LOS (p < 0.01) with no significant differences in discharge destinations. For those with a GCS of 4-8, ICP monitoring was associated with a longer LOS (p = 0.01), but fewer were discharged to a skilled nursing facility or long-term care (p = 0.01).

Conclusions: For TBI patients, ICP monitoring was associated with an increased LOS, with no significant differences in discharge destinations when compared to those without ICP monitoring. However, among only those with a GCS of 4-8, ICP monitoring was associated with a decreased proportion of patients discharged to a skilled nursing facility or long-term acute care .